Skilled nursing facility admissions of nursing home residents with advanced dementia.

OBJECTIVES: To describe the extent to which hospitalized nursing home (NH) residents with advanced dementia were admitted to a skilled nursing facility (SNF) after a qualifying hospitalization and to identify resident and nursing home characteristics associated with a greater likelihood of SNF admissions. DESIGN: Cohort study using data from the Minimum Data Set, Medicare claims, and the On-line Survey Certification of Automated Records. SETTING: United States, 2000-2006. PARTICIPANTS: Nursing home residents with advanced dementia aged 65 and older with a 3-day hospitalization (N = 4,177). MEASUREMENTS: The likelihood of SNF admission after hospitalization was calculated. Resident and nursing home factors associated with SNF admission were identified using hierarchical multivariable logistic regression. RESULTS: Sixty-one percent of residents with advanced dementia were admitted to a SNF after their hospitalization. Percutaneous endoscopic gastrostomy (PEG) tube placement during hospitalization was strongly associated with SNF admission (adjusted odds ratio (AOR) = 2.31, 95% confidence interval (CI) = 1.85-2.88), as was better functional status (AOR = 1.21, 95% CI = 1.05-1.38). The presence of diabetes mellitus was associated with lower likelihood of SNF admission (AOR = 0.85, 95% CI = 0.73-0.99). Facility features significantly associated with SNF admission included more than 100 beds (AOR = 1.25, 95% CI = 1.07-1.46), being part of a chain (AOR = 1.31, 95% CI = 1.14-1.50), urban location (AOR = 1.21, 95% CI = 1.03-1.41), and for-profit status (AOR = 1.28, 95% CI = 1.09-1.51). CONCLUSION: The majority of nursing home residents with advanced dementia are admitted to SNFs after a qualifying hospitalization. SNF admission is strongly associated with PEG tube insertion during hospitalization and with nursing home factors. Efforts to optimize appropriate use of SNF services in individuals with advanced dementia should focus on these factors.

Do patients with advanced cognitive impairment admitted to hospitals with higher rates of feeding tube insertion have improved survival?

CONTEXT: Research is conflicting on whether receiving medical care at a hospital with more aggressive treatment patterns improves survival. OBJECTIVES: The aim of this study was to examine whether nursing home residents admitted to hospitals with more aggressive patterns of feeding tube insertion had improved survival. METHODS: Using the 1999-2007 Minimum Data Set matched to Medicare claims, we identified hospitalized nursing home residents with advanced cognitive impairment who did not have a feeding tube inserted prior to their hospital admissions. The sample included 56,824 nursing home residents and 1773 acute care hospitals nationwide. Hospitals were categorized into nine groups based on feeding tube insertion rates and whether the rates were increasing, staying the same, or decreasing between the periods of 2000-2003 and 2004-2007. Multivariate logit models were used to examine the association between the hospital patterns of feeding tube insertion and survival among hospitalized nursing home residents with advanced cognitive impairment. RESULTS: Nearly one in five hospitals (N=366) had persistently high rates of feeding tube insertion. Being admitted to these hospitals with persistently high rates of feeding tube insertion was not associated with improved survival when compared with being admitted to hospitals with persistently low rates of feeding tube insertion. The adjusted odds ratios were 0.93 (95% confidence interval [CI]: 0.87, 1.01) and 1.02 (95% CI: 0.95, 1.09) for one-month and six-month posthospitalization survival, respectively. CONCLUSION: Hospitals with more aggressive patterns of feeding tube insertion did not have improved survival for hospitalized nursing home residents with advanced cognitive impairment.

Does feeding tube insertion and its timing improve survival?

OBJECTIVES: To examine survival with and without a percutaneous endoscopic gastrostomy (PEG) feeding tube using rigorous methods to account for selection bias and to examine whether the timing of feeding tube insertion affected survival. DESIGN: Prospective cohort study. SETTING: All U.S. nursing homes (NHs). PARTICIPANTS: Thirty-six thousand four hundred ninety-two NH residents with advanced cognitive impairment from dementia and new problems eating studied between 1999 and 2007. MEASUREMENTS: Survival after development of the need for eating assistance and feeding tube insertion. RESULTS: Of the 36,492 NH residents (88.4% white, mean age 84.9, 87.4% with one feeding tube risk factor), 1,957 (5.4%) had a feeding tube inserted within 1 year of developing eating problems. After multivariate analysis correcting for selection bias with propensity score weights, no difference was found in survival between the two groups (adjusted hazard ratio (AHR) = 1.03, 95% confidence interval (CI) = 0.94-1.13). In residents who were tube-fed, the timing of PEG tube insertion relative to the onset of eating problems was not associated with survival after feeding tube insertion (AHR = 1.01, 95% CI = 0.86-1.20, persons with a PEG tube inserted within 1 month of developing an eating problem versus later (4 months) insertion). CONCLUSION: Neither insertion of PEG tubes nor timing of insertion affect survival.

Feeding tubes and the prevention or healing of pressure ulcers.

BACKGROUND: The evidence regarding the use of feeding tubes in persons with advanced dementia to prevent or heal pressure ulcers is conflicting. Using national data, we set out to determine whether percutaneous endoscopic gastrostomy (PEG) tubes prevent or help heal pressure ulcers in nursing home (NH) residents with advanced cognitive impairment (ACI). METHODS: A propensity-matched cohort study of NH residents with ACI and recent need for assistance in eating was conducted by matching each NH resident who had a feeding tube inserted during a hospitalization to 3 without a PEG tube inserted. Using the Minimum Data Set (MDS), we examined 2 outcomes: first, whether residents without a pressure ulcer developed a stage 2 or higher pressure ulcer (n = 1124 with PEG insertion); and second, whether NH residents with a pressure ulcer (n = 461) experienced improvement of the pressure ulcer by their first posthospitalization MDS assessment (mean [SD] time between evaluations, 24.6 [32.7] days). RESULTS: Matched residents with and without a PEG insertion showed comparable sociodemographic characteristic, rates of feeding tube risk factors, and mortality. Adjusted for risk factors, hospitalized NH residents receiving a PEG tube were 2.27 times more likely to develop a new pressure ulcer (95% CI, 1.95-2.65). Conversely, those with a pressure ulcer were less likely to have the ulcer heal when they had a PEG tube inserted (OR 0.70 [95% CI, 0.55-0.89]). CONCLUSIONS: Feeding tubes are not associated with prevention or improved healing of a pressure ulcer. Rather, our findings suggest that the use of PEG tube is associated with increased risk of pressure ulcers among NH residents with ACI.

Does hospice improve quality of care for persons dying from dementia?

OBJECTIVES: To examine the effectiveness of hospice services for persons dying from dementia from the perspective of bereaved family members. DESIGN: Mortality follow-back survey. SETTING: Death certificates were drawn from five states (AL, FL, TX, MA, and MN). PARTICIPANTS: Bereaved family members listed as the next of kin on death certificates when dementia was listed as the cause of death. MEASUREMENTS: Ratings of the quality of end-of-life care, perceptions of unmet needs, and opportunities to improve end-of-life care. Two questions were also asked about the peacefulness of dying and quality of dying. RESULTS: Of 538 respondents, 260 (48.3%) received hospice services. Family members of decedents who received hospice services reported fewer unmet needs and concerns with quality of care (adjusted odds ratio (AOR)=0.49, 95% confidence interval (CI)=0.33-0.74) and a higher rating of the quality of care (AOR=2.0, 95% CI=1.53-2.72). They also noted better quality of dying than those without hospice services. CONCLUSION: Bereaved family members of people with dementia who received hospice reported higher perceptions of the quality of care and quality of dying.

Implementing small group health insurance reform: the HEALTHpact plan of Rhode Island.

This study analyzes administrative impediments to enrollment in HEALTHpact, a high-deductible plan with premiums capped at 10% of the average Rhode Island wage. HEALTHpact includes an opportunity for enrollees to reduce their deductibles from $5,000 ($10,000 for a family) to $750 ($1,500 for a family) if they engage in prespecified wellness behaviors. A stakeholder panel was convened to develop guidelines for insurers, which, in turn, were required to develop products satisfying those guidelines. Implementation was examined using stakeholder interviews and archival documents. Results indicate that since no funds were allocated for education and monitoring, there was little opportunity to promote "bottom up" demand or to oversee insurers. They also indicate that both insurers and brokers adopted strategies that inhibited take-up. Providing the resources necessary for effective government oversight and outreach will be critical to small group market reform nationally. So too will be promoting broker and insurer buy-in.

Decision-making and outcomes of feeding tube insertion: a five-state study.

OBJECTIVES: To examine family member's perceptions of decision-making and outcomes of feeding tubes. DESIGN: Mortality follow-back survey. Sample weights were used to account for oversampling and survey design. A multivariate model examined the association between feeding tube use and overall quality of care rating regarding the last week of life. SETTING: Nursing homes, hospitals, and assisted living facilities. PARTICIPANTS: Respondents whose relative had died from dementia in five states with varying feeding tube use. MEASUREMENTS: Respondents were asked about discussions, decision-making, and outcomes related to their loved ones' feeding problems. RESULTS: Of 486 family members surveyed, representing 9,652 relatives dying from dementia, 10.8% reported that the decedent had a feeding tube, 17.6% made a decision not to use a feeding tube, and 71.6% reported that there was no decision about feeding tubes. Of respondents for decedents with a feeding tube, 13.7% stated that there was no discussion about feeding tube insertion, and 41.6% reported a discussion that was shorter than 15 minutes. The risks associated with feeding tube insertion were not discussed in one-third of the cases, 51.8% felt that the healthcare provider was strongly in favor of feeding tube insertion, and 12.6% felt pressured by the physician to insert a feeding tube. The decedent was often physically (25.9%) or pharmacologically restrained (29.2%). Respondents whose loved ones died with a feeding tube were less likely to report excellent end-of-life care (adjusted odds ratio=0.42, 95% confidence interval=0.18-0.97) than those who were not. CONCLUSION: Based on the perceptions of bereaved family members, important opportunities exist to improve decision-making in feeding tube insertion.

Small group health insurance reform in Rhode Island: promises and pitfalls of the HEALTHpact plan.

OBJECTIVE: This study analyzes what design elements inhibited enrollment in HEALTHpact. STUDY SETTING: HEALTHpact is a high deductible plan with a premium capped at 10 percent of the average Rhode Island wage. Deductibles are reduced if enrollees meet wellness criteria. STUDY DESIGN: Qualitative case study. DATA COLLECTION: Archival documents and 23 interviews. PRINCIPAL FINDINGS: Inclusion of a subsidy would have led to lower premiums and more generous coverage. Although priced lower than other plans, HEALTHpact still did not offer good value for most firms. Wellness incentives also were too complex. CONCLUSIONS: Subsidies for purchase of insurance coverage are critical to national reform of the small group market. Designers also will need to carefully balance program complexity with innovation in encouraging wellness and product appeal.

Do Medicaid wage pass-through payments increase nursing home staffing?

OBJECTIVE: To assess the impact of state Medicaid wage pass-through policy on direct-care staffing levels in U.S. nursing homes. DATA SOURCES: Online Survey Certification and Reporting (OSCAR) data, and state Medicaid nursing home reimbursement policies over the period 1996-2004. STUDY DESIGN: A fixed-effects panel model with two-step feasible-generalized least squares estimates is used to examine the effect of pass-through adoption on direct-care staff hours per resident day (HPRD) in nursing homes. DATA COLLECTION/EXTRACTION METHODS: A panel data file tracking annual OSCAR surveys per facility over the study period is linked with annual information on state Medicaid wage pass-through and related policies. PRINCIPAL FINDINGS: Among the states introducing wage pass-through over the study period, the policy is associated with between 3.0 and 4.0 percent net increases in certified nurse aide (CNA) HPRD in the years following adoption. No discernable pass-through effect is observed on either registered nurse or licensed practical nurse HPRD. CONCLUSIONS: State Medicaid wage pass-through programs offer a potentially effective policy tool to boost direct-care CNA staffing in nursing homes, at least in the short term.

Natural history of feeding-tube use in nursing home residents with advanced dementia.

OBJECTIVES: Despite the evidence that feeding-tube use in persons with advanced dementia is not associated with improved outcomes, there remains striking variation in their use. Yet, little is known about the national incidence of feeding-tube insertions, the circumstances of their insertion, and post-insertion health care use. DESIGN: Secondary analysis of Minimum Data Set merged onto Medicare Claims Files. SETTING AND PARTICIPANTS: Nursing home residents (NHR) without a feeding tube. MEASUREMENTS: NHR were followed for up to 1 year to see whether a feeding tube was inserted and then followed for 1 year after insertion to examine health care use and survival. RESULTS: The incidence of feeding-tube insertion was 53.6/1000 residents. Most (68.1%) feeding-tube insertions were performed in an acute care hospital with the most common reasons for admission being pneumonia, dehydration, and dysphagia. One year post-insertion mortality was 64.1% with median survival of 56 days. Within 1 year, 19.3% of those who had a feeding tube inserted required a tube replacement or repositioning within a median 145 days after the initial insertion. Over 1 year, tube feeding was associated with an average of 9.1 hospitalized days per person, 1.0 hospitalizations, 0.3 emergency room visits that did not result in a hospital admission. CONCLUSION: Most feeding tubes are inserted in an acute care hospital. Feeding-tube insertions are also associated with poor survival and significant rate of health care use after insertion.

Churning: the association between health care transitions and feeding tube insertion for nursing home residents with advanced cognitive impairment.

BACKGROUND: There is a tenfold variation across U.S. states in the prevalence of feeding tube use among elderly nursing home residents (NHR) with advanced cognitive impairment. The goal of this study was to examine whether regions with higher rates of health care transitions at the end of life are more likely to use feeding tubes in patients with severe cognitive impairment. METHODS: A retrospective cohort study of U.S. nursing home residents with advanced cognitive impairment. The incidence of feeding tube insertion was determined by Medicare Part A and B billing data. A count of the number of health care transition in the last 6 months of life was determined for nursing home residents. A multivariate model examined the association of residing in a geographic region with a higher rates of health care transition and the insertion of a feeding tube in nusing home resident with advance cognitive impairment. RESULTS: Hospital Referral Region (HRR) health care transitions varied from 192 (Salem, Oregon) to 509 per 100 decedents (Monroe, Louisiana) within the last 6 months of life. HRRs with higher transition rates had a higher incidence of feeding tube insertion (Spearman correlation = 0.58). Subjects residing in regions with the highest quintile of transitions rates were 2.5 times (95% confidence interval [CI] 1.9-3.2) more likely to have a feeding tube inserted compared to those that resided in the lowest quintile. CONCLUSIONS: Regions with higher rates of care transitions among nursing home residents are also much more likely to have higher rates of feeding tube placement for patients with severe cognitive impairment, a population in whom benefit is unlikely.

Do financial incentives of introducing case mix reimbursement increase feeding tube use in nursing home residents?

OBJECTIVES: To determine whether adoption of Medicaid case mix reimbursement is associated with greater prevalence of feeding tube use in nursing home (NH) residents. DESIGN: Secondary analysis of longitudinal administrative data about the prevalence of feeding tube insertion and surveys of states' adoption of case mix reimbursement. SETTING: NHs in the United States. PARTICIPANTS: NH residents at the time of NH inspection between 1993 and 2004. MEASUREMENTS: Facility prevalence of feeding tubes reported at the state inspection of NHs reported in the Online Survey, Certification and Reporting database and interviews with state policy makers regarding the adoption of case mix reimbursement. RESULTS: Between 1993 and 2004, 16 states adopted Resource Utilization Group case mix reimbursement. States varied in the prevalence of feeding tubes in their NHs. Although the use of feeding tube increased substantially over the years of the study, once temporal trends and facility fixed effects were accounted for, case mix reimbursement was not associated with greater prevalence of feeding tube use. CONCLUSION: The adoption of Medicaid case mix reimbursement was not associated with an increase in the prevalence of feeding tube use.

The transition from excess capacity to strained capacity in U.S. hospitals.

After many years of concern about excess hospital capacity, a growing perception exists that the capacity of some hospitals now seems constrained. This article explores the reasons behind this changing perception, looking at the longitudinal data and in-depth interviews for hospitals in four study sites monitored by the Community Tracking Study of the Center for Studying Health System Change. Notwithstanding the differences for individual hospitals, we observed that adjustments to the supply of hospital services tend to be slow and out of sync with changes in the demand for hospital services. Those hospitals reporting capacity problems are often teaching hospitals, located near previously closed facilities or in population growth areas. These findings suggest therefore that approaches to dealing with capacity problems might best focus on better matching individual hospitals' supply and demand adjustments.

Translating research to action: improving physician access in public insurance.

Policymakers continue to struggle with how to assure adequate access to physician services in public programs like Medicaid, State Children's Health Insurance Program, or other public coverage programs. In this article, we synthesize available research on this topic and provide a framework that policymakers may find useful in identifying and measuring barriers to care access, determining where and why problems exist, and identifying how to intervene. Using our experience constructing the framework, we also consider what observations can be drawn from this experience for those interested in the challenge of moving the insights from research to practice.

Trends in care practices and outcomes among Medicare beneficiaries with diabetes.

BACKGROUND: While diabetes is a major issue for the aging U.S. population, few studies have described the recent trends in both preventive care practices and complications among the Medicare population with diabetes. Using the Medicare Quality Monitoring System (MQMS), this 2004 study describes these trends from 1992 to 2001 and how these rates vary across demographic subgroups. METHODS: Outcomes include age- and gender-adjusted rates of 15 indicators associated with diabetes care from 1992 to 2001, the absolute change in rates from 1992 to 2001, and 2001 rates by demographic subgroups. The data were cross-sectional samples of Medicare beneficiaries with diabetes from 1992 to 2001 from the Medicare 5% Standard Analytic Files. RESULTS: Use of preventive care practices rose from 1992 to 2001: 45 percentage points for HbA1c tests, 51 for lipid tests, 8 for eye exams, and 38 for self-monitoring of glucose levels (all p<0.05). Rates for short-term and some long-term complications of diabetes (e.g., lower-extremity amputations and cardiovascular conditions) fell from 1992 to 2001 (p<0.05). However, rates of other long-term complications such as nephropathy, blindness, and retinopathy rose during the period (p<0.05). Nonwhites and beneficiaries aged <65 and >85 exhibited consistently higher complication rates and lower use of preventive services. CONCLUSIONS: The Medicare program has seen some significant improvement in preventive care practices and significant declines in lower-limb amputations and cardiovascular conditions. However, rates for other long-term complications have increased, with evidence of subgroup disparities. The MQMS results provide an early warning for policymakers to focus on the diabetes care provided to some vulnerable subgroups.

Health care market trends and the evolution of hospitalist use and roles.

OBJECTIVE: To describe local health care market dynamics that support increasing use of hospitalists' services and changes in their roles. DESIGN: Semistructured interviews in 12 randomly selected, nationally representative communities in the Community Tracking Study conducted in 2002-2003. Interviews were coded in qualitative data analysis software. We identified patterns and themes within and across study sites, and verified conclusions by triangulating responses from different respondent types, examining outliers, searching for corroborating or disconfirming evidence, and testing rival explanations. SETTING: Medical groups, hospitals, and health plans in 12 representative communities. PARTICIPANTS: One hundred seven purposively sampled executives at the 3-4 largest medical groups, hospitals, and health plans in each community: medical directors and medical staff presidents; chief executive and managing officers; executives responsible for contracting, physician networks, hospital patient safety, patient care services, planning, and marketing; and local medical and hospital association leaders. MEASUREMENTS AND MAIN RESULTS: We asked plan and hospital respondents about their competitive strategies, including their experience with cost pressures, hospital patient flow problems, and hospital patient safety efforts. We asked all respondents about changes in their local market over the past 2 years generally, and specifically: hospitals' and physicians' responses to market pressures; payment arrangements hospitals and physicians had with private health plans; and physicians' relationships with plans and hospitals. We drew on data on hospitalist practice structures, employment relationships, and productivity/compensation from the Society for Hospital Medicine's 2002 membership survey. Factors that fomented the creation of the hospital medicine movement persist, including cost pressures and primary care physicians' decreasing inpatient volume. But emerging influences made hospitalists even more attractive, including worsening problems with patient flow in hospitals, rising malpractice costs, and the growing national focus on patient safety. Local market forces resulted in new hospitalist roles and program structures, regarding which organizations sponsored hospitalist programs, employed them, and the functions they served in hospitals. CONCLUSIONS: These findings have important implications for patients, hospitalists, and their employers. Hospitalists may require changes in education and training, develop competing goals and priorities, and face new issues in their relationships with health plans, hospitals, and other physicians.

Does U.S. hospital capacity need to be expanded?

Some industry experts believe that U.S. hospital capacity--especially emergency and inpatient services--is being stretched to its limits. Using data from the Community Tracking Study, this paper examines constrained hospital services, contributing factors, and hospitals' responses. Most hospitals studied had emergency capacity problems, but problems in other service areas were limited to only a few hospitals. Hospitals have added or converted capacity, improved capacity management, dealt with nursing shortages, and worked with public officials to reduce emergency department diversions. Although additional capacity might be needed in some markets, better management of existing resources could be a more effective solution.

Medical malpractice liability crisis meets markets: stress in unexpected places.

While the causes of rapidly rising medical malpractice insurance premiums remain contentious and unsettled, the consequences are rippling through communities, threatening to diminish patients' access to care and increase health care costs, with an uncertain impact on quality, according to findings from the Center for Studying Health System Change's (HSC) 2002-03 site visits to 12 nationally representative communities. The severity of malpractice insurance problems varied across communities, with some physicians changing how and where they care for patients. For example, rather than treat patients in their offices, more physicians are referring patients to emergency departments. And many physicians, especially those practicing in high-risk specialties, are unwilling to provide emergency department on-call coverage because of malpractice liability concerns.